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MR Arthrography - Shoulder

Direct MR arthrography distends the glenohumeral joint with dilute gadolinium, separating intra-articular structures and allowing contrast to outline tears of the labrum, capsule and articular surface of the rotator cuff. It substantially improves sensitivity for labral and partial-thickness cuff pathology compared with conventional MRI, and is the reference test in the young unstable or post-operative shoulder.

Indications

  • Suspected glenoid labral tears including SLAP and Bankart lesions
  • Shoulder instability and evaluation of the capsulolabral complex
  • Partial-thickness (particularly articular-surface) and small rotator cuff tears
  • Assessment of the post-operative cuff and labrum where fluid signal is equivocal
  • Suspected biceps anchor and superior labral pathology
  • Evaluation of adhesive capsulitis and capsular volume

Contraindications & Cautions

  • Non-conditional pacemakers, ICDs, neurostimulators and ferromagnetic implants
  • Active infection or cellulitis over the injection site
  • Known allergy to gadolinium or iodinated contrast used for needle localisation
  • Bleeding diathesis or anticoagulation increasing haemarthrosis risk (relative)
  • Pregnancy: relative caution; the intra-articular gadolinium dose is small but justify the study

Patient Preparation

  • Explain the two-stage procedure: image-guided injection followed by MRI
  • Obtain informed consent for the arthrogram and screen for contrast allergy
  • Aseptic technique; fluoroscopic or ultrasound-guided anterior (rotator interval) or posterior approach
  • Inject 12-15 mL of dilute gadolinium (approximately 2 mmol/L, ~1:200 in saline) to distend the joint
  • Move the patient promptly to the scanner and image within ~30-45 minutes before contrast resorption

Technique & Parameters

  • Fat-saturated T1-weighted sequences in axial, oblique coronal and oblique sagittal planes
  • At least one fluid-sensitive sequence (T2 or PD fat-sat) to detect extra-articular fluid and marrow oedema
  • Abduction-external rotation (ABER) view to open the antero-inferior labrum and articular cuff
  • Small field-of-view with a dedicated shoulder coil for high spatial resolution
  • Optional traction or specific positioning to improve labral separation
  • 1.5T or 3T; 3T offers superior resolution for subtle labral and cuff tears

Systematic Review

  • Confirm adequate joint distension by intra-articular contrast
  • Trace the labrum clock-face, assessing each quadrant for contrast undercutting a tear
  • Evaluate the superior labrum and biceps anchor for SLAP lesions
  • Assess the articular surface of the supraspinatus/infraspinatus for contrast tracking into a tear
  • Inspect the capsule, inferior glenohumeral ligament and HAGL, and the rotator interval
  • Review the humeral head and glenoid for Hill-Sachs and bony Bankart lesions on the fluid-sensitive series

Key Findings & Significance

  • Bankart lesion: antero-inferior labral tear with contrast undercutting, +/- bony fragment (bony Bankart)
  • SLAP lesion: contrast extending into the superior labrum at the biceps anchor, best on coronal images
  • Perthes and ALPSA variants: labroligamentous stripping with periosteal sleeve or medially displaced labrum
  • Articular-surface partial-thickness rotator cuff tear: contrast tracking into the cuff undersurface without full extension
  • HAGL lesion: contrast extravasation through a disrupted inferior glenohumeral ligament at its humeral attachment
  • Adhesive capsulitis: reduced joint volume, thickening of the capsule and rotator interval

Differential Considerations

  • Superior labral high signal: SLAP tear versus normal sublabral recess or foramen and Buford complex variant
  • Antero-inferior labral abnormality: Bankart, Perthes, ALPSA, GLAD lesions
  • Cuff undersurface irregularity: partial tear versus tendinosis or normal footprint
  • Paralabral cyst with signal: labral tear versus ganglion
  • Capsular thickening: adhesive capsulitis versus normal variation

Pearls & Pitfalls

  • Know the normal variants (sublabral recess, sublabral foramen, Buford complex) to avoid overcalling a SLAP tear
  • The ABER position tensions the antero-inferior band and improves detection of non-displaced Bankart and articular cuff tears
  • Contrast tracking into a structure is the hallmark of a communicating tear; intrasubstance signal alone may be degeneration
  • A Buford complex (absent antero-superior labrum with a cord-like middle glenohumeral ligament) must not be mistaken for a tear
  • Always include a fluid-sensitive sequence to detect marrow oedema, extra-articular fluid and paralabral cysts

Structured Report

  • State the injection approach, contrast volume and field strength
  • Confirm joint distension and describe labral integrity by location/clock-face
  • Report rotator cuff articular and bursal surfaces and any tear extent
  • Describe capsule, glenohumeral ligaments, HAGL and biceps anchor
  • Note bony lesions (Hill-Sachs, bony Bankart) and provide a surgical-oriented impression

References

  • ACR-SSR Practice Parameter for the Performance and Interpretation of MR Arthrography
  • Steinbach LS, et al. Radiographics: MR arthrography of the shoulder
  • Waldt S, et al. Anterior shoulder instability: MR arthrographic classification. Radiology
  • Chang EY, et al. MR arthrography of the shoulder: technique and pathology

Educational clinical decision support only. Protocols vary by institution and equipment; always confirm with a qualified radiologist and local guidelines before clinical use.